Exam 4 - Rheumatoid Arthritis Flashcards
What are risk factors for rheumatoid arthritis? (2)
sex (women), Caucasian and Native American
List characteristics of rheumatoid arthritis? (4)
variable age and onset, bilateral and generalized to smaller joints, >1 hr pain associated with use and rest, autoantibodies present
What are non-pharm treatments for rheumatoid arthritis? (5)
rest, weight loss, pain coping skills, physical/occupation therapy, surgery
What are nDMARDs for rheumatoid arthritis? (2)
NSAIDs, corticosteroids
What is initial pharmacologic treatment for rheumatoid arthritis?
DMARD monotherapy
What is pharmacologic treatment for persistent moderate-high disease activity rheumatoid arthritis? (3)
combination csDMARDs, bDMARD or tsDMARD both +/- MTX (* = short-term corticosteroids)
What is treatment for persistent moderate-high disease RA with prior csDMARD use other than MTX?
switch to MTX monotherapy
What is treatment for persistent moderate-high disease RA with oral MTX not at target?
switch to SQ MTX (potentially over addition of DMARD)
What is treatment for persistent moderate-high disease RA without poor prognostic factors/patient preference?
add additional csDMARD
What is treatment for persistent moderate-high disease RA with poor prognostic factors/patient preference?
add tsDMARD or bDMARD
What are the poor prognostic factors for rheumatoid arthritis? (3)
high disease activity, early presence of erosion, autoantibody positivity
What are the conventional synthetic (cs) DMARDs? (9)
methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, gold salts, minocycline, CsA, cyclophosphamide, D-penicillamine
What are the biologic (b) DMARDs? (2)
TNF inhibitors (etanercept, infliximab, adalimumab, golimumab, certolizumab) and non-TNF inhibitors (abatacept, rituximab, toclizumab, anakinra, sarilumab)
What are the targeted synthetic (ts; JAKis) DMARDs? (3)
tofacitinib, baricitinib, upadacitinib
What is the MOA of methotrexate?
folate antagonist with anti-inflammatory properties
How is methotrexate dosed?
7.5 mg qw, titrated to 15 mg
What are AEs of methotrexate? (3)
stomatitis, dyspepsia, immunosuppression
What are boxed warnings for methotrexate? (5)
GI toxicity, dermatological reactions, pneumonitis/pulmonary fibrosis, myelosuppression, increased LFTs
What are contraindications for methotrexate? (4)
pregnancy/breastfeeding, renal disease, liver disease, myelosuppression
What is the MOA of leflunomide?
inhibits pyrimidine synthesis to decrease lymphocyte proliferation
How is leflunomide dosed?
100 mg qd x 3, then 10-20 mg/d
What are AEs of leflunomide? (5)
GI, rash, alopecia, peripheral neuropathy, HTN
What are boxed warnings for leflunomide? (3)
embryo-fetal toxicity, hepatotoxicity, drug elimination may be necessary with cholestyramine
What is the MOA of sulfasalazine?
unknown; metabolites have anti-inflammatory properties
How is sulfasalazine dosed?
500-1000 mg/d
What are AEs for sulfasalazine? (6)
GI, HA, rash, weight loss, oligospermia, hemolytic anemia
What is the MOA of hydroxychloroquine?
unknown; inhibits cytokine production
How is hydroxychloroquine dosed?
400-600 mg/d, then 200-400 mg/d
What are AEs of hydroxychloroquine? (4)
GI, retinal damage, QTc-prolongation, skin reactions (allergic, pigmentation)
What are the onsets of action for the csDMARDs? (4)
MTX = 1-2, leflunomide = 1-3, sulfasalazine = 1-3, hydroxychloroquine = 2-4 mo
What is the order of recommended csDMARDs for initial therapy in low disease activity?
hydroxychloroquine > sulfasalazine > methotrexate > leflunomide
What time frame is considered an adequate trial for TNFi biologics? Non-TNFi biologics?
3 mo; 6 mo
Which TNFi biologics are SQ only? (3)
etanercept, adalimumab, certolizumab
Which TNFi biologic is IV only?
infliximab
What are boxed warnings for TNFi biologics? (2)
malignancy, opportunistic infections
How is adalimumab dosed when on methotrexate in RA? When taken alone?
40 mg eow; 40 mg qw
Which non-TNFi biologics are SQ only? (2)
sarilumab, anakinra
Which non-TNFi biologic is IV only?
rituximab
Which biologics MUST be given with methotrexate? (2)
rituximab, golimumab
What are AEs of biologics? (2)
infections (URTIs/UTIs), injection site/infusion-related reactions
What are monitoring parameters for biologics? (4)
CBC (all), LFT (infliximab), ANC, FLP
What are AEs of JAKis? (4)
increased HDL/LDL, infections (URTIs), GI perforation, blood dyscrasias
What are boxed warnings for JAKis? (3)
malignancy, opportunistic infections, thrombotic events
What is first-line treatment for DMARD-naïve RA patients with moderate-severe disease?
methotrexate
What is first-line treatment for DMARD-naïve RA patients with low (mild) disease?
hydroxychloroquine
Which vaccinations are recommended during RA therapy with biologics? (3)
pneumococcal, influenza, hepatitis B
What should be tested for prior to starting a biologic or JAKi? For how long? (2)
tuberculosis; if latent 1 month prior to starting biologic, if active after complete TB treatment
